Provider Demographics
NPI:1063590891
Name:CHAIKHOUTDINOV, MARAT G (MD)
Entity type:Individual
Prefix:
First Name:MARAT
Middle Name:G
Last Name:CHAIKHOUTDINOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 KINGS HWY
Mailing Address - Street 2:5C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-1525
Mailing Address - Country:US
Mailing Address - Phone:718-513-4386
Mailing Address - Fax:
Practice Address - Street 1:1513 VOORHIES AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3994
Practice Address - Country:US
Practice Address - Phone:718-332-4440
Practice Address - Fax:718-332-5089
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87766207Q00000X
NY240497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A877660Medicaid
NY02823449Medicaid
I28306Medicare UPIN
CA00A877660Medicaid
00A877660Medicare ID - Type Unspecified